This certainly isn’t the first make-or-break week for health care reform since the debate began a year ago, but it might be the last if President Obama doesn’t use his State of the Union address on Wednesday night to inspire congressional Democrats — or entice some Republicans. That, at least, was the message late last week as confusion reigned in the aftermath of Republican Scott Brown’s shocking Senate win in Massachusetts. Obama spent the weekend on the phone with congressional leaders trying to plot the path forward, a top aide said Sunday, while Speaker Nancy Pelosi and Majority Leader Harry Reid tried to cobble together a package of changes to the Senate bill that would make the legislation more palatable to rank-and-file House Democrats. As Chris Frates, the usual author of this e-mail, reported Friday, “The changes being considered track closely with the agreements House and Senate leaders made in White House meetings last week,” such as the deal to raise the threshold on high-end health care plans that would be taxed under the legislation. But no one seems to know whether House Democrats would accept this plan — or if lawmakers will still stomach such an ambitious bill after Massachusetts. With this backdrop, all eyes turn to President Obama to see if he can turn in another clutch performance Wednesday night to save his top legislative priority.

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Five questions moving forward: Democrats have their work cut out for them to revive the health care bill after Massachusetts, so Carrie and I explored five critical questions that should shape how the party proceeds: 1) Will Senate Majority Leader Harry Reid pursue reconciliation? 2) How close will the House come to the Senate? 3) Can you actually do a scaled-down bill, given how interconnected the legislation is? 4) How many "yeas" have become "nays"? And 5) How hard will Obama push?

The question of reconciliation is first among equals. The challenge of moving a package of fixes through reconciliation “is to avoid making it look like a messy stew of legislative deal making’ — which won’t be easy to do because one of the main things the bill is likely to fix is the so-called Cadillac tax, which would exempt union members through 2017. Try selling that to a public already upset about Sen. Ben Nelson’s so-called Cornhusker Kickback, which exempts his state from reform-related Medicaid increases forever. (The cleanup bill might eliminate the Nebraska provision, too, sources say, but the PR damage has already been done.) In terms of pure mathematics, it seems that Reid could muster 51 votes out of the 59-member Democratic Caucus. But there’s a political equation as well. Even some Democrats are urging him to go slow, including centrists like Sen. Evan Bayh (D-Ind.).”

Exclusive: The day after Obama delivers his State of the Union address, the departments of Justice and Health and Human Services will hold a joint summit at the National Institutes of Health to highlight the problem of health care fraud. The all-day session will put law enforcement officials in the same room with private practitioners and public sector officials to discuss what both sides can do to limit a persistent problem that costs Medicare and Medicaid billions each year. Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius will both participate.

** The Center for Medicine in the Public Interest Advance opposes government-run health care. Is an unelected health care “czar” really any better than a public plan? Learn more at www.handsoffmyhealth.org. **

No surprise here: Health insurers shell out for lobbyists, The Hill’s Kevin Bogardus reports: “America’s largest insurance companies spent millions more on lobbying last year as lawmakers debated health care reform, lobbying disclosure records show. Overall, the companies increased lobbying spending by an average of 24 percent from 2008 to 2009, according to an analysis by The Hill of disclosure reports released this week. The list includes insurance giants such as Aetna and Wellpoint along with the industry’s major trade association, America’s Health Insurance Plans (AHIP). ... Humana, based in Louisville, Ky., showed the biggest increase in its lobbying spending among the insurers. The company spent roughly $3.2 million on lobbying in 2009, almost 80 percent more than the $1.8 million it spent in 2008. The largest spender among the insurance companies though was Wellpoint. The Indianapolis-based company spent about $4.7 million in 2009 on lobbying, 21 percent more than its K Street expenditures in 2008. ... But the individual companies’ spending on lobbyists does not match their industry association, AHIP. The trade group spent about $8.9 million on lobbyists in 2009, according to disclosure forms. That is almost 20 percent more than the business association spent on lobbying in 2008.”

The White House sets its sights a little lower, reports WSJ’s Janet Adamy: "The White House, with its health-care initiative in doubt, on Sunday zeroed in on several elements it hoped would survive, including measures to extend the life of Medicare, lower prescription drug costs for seniors and cap consumers' out-of-pocket medical expenses … Comments Sunday indicated that any revamped legislation would likely focus on the least-controv.ersial elements of earlier proposals ... President Barack Obama spoke with congressional leaders over the weekend to determine how to move forward on the issue. ... White House adviser David Axelrod, appearing on ABC News's "This Week," said the president didn't want to abandon several elements of the current bills. These include extending the life of the Medicare insurance program for the elderly, which the bills propose to do through payment cuts to health providers and issuing tax breaks to help small employers provide insurance. … Mr. Axelrod also cited assistance to help seniors pay for prescription drugs. … He also said the overhaul should help people with pre-existing health conditions buy insurance and cap out-of-pocket medical costs. He didn't discuss how these measures would be paid for.” As Adamy points out, Axelrod and others avoided talking about expanding coverage — a key plank of the House and Senate bills.

The White House downplays Massachusetts: In damage-control mode, POLITICO’s Carol E. Lee reports: “Top White House aides spent several hours Sunday morning trying to put the best face on the Massachusetts election that stripped President Barack Obama of a 60-seat Democratic supermajority in the Senate and left his health care legislation in serious doubt. Their overall message was that some type of health care reform will pass, yet there appeared to be disagreement over whether the bill that congressional Democrats and the White House had been working on in conference was actually dead. Press secretary Robert Gibbs and senior adviser Valerie Jarrett said the White House is working with members of Congress to determine ‘what’s the art of the possible,’ as Jarrett put it on NBC’s ‘Meet the Press.’ ‘We don’t know quite what that is yet,’ Gibbs said on ‘Fox News Sunday.’ But senior adviser David Axelrod, in multiple appearances, dismissed the suggestion that the current bill is dead and told TV One ‘Washington Watch’ host Roland Martin that passing it ‘would be good politics.’”

Axelrod doesn't love the process, either: Amid complaints from Massachusetts voters and Democrats on Capitol Hill, one of the president's top political advisers admits the extended debate turned people off from health care reform. "The process, eight months of debate, were less than satisfying and that was clear," Axelrod said on ABC's "This Week." "And if you look at the polls out of Massachusetts, people reacted as much to the process as anything else. Were there things we could have done there? Perhaps. We have to think that through."

Insurers battle hospitals: Whatever the fate of the health care bill, insurers are already locked in a bitter battle with health care providers to curb costs. NYT’s Anemona Hartocollis reports: "While Congress has been haggling over covering as many as 15 million uninsured Americans, the prestigious hospitals and the major health insurer have been in bitter contract negotiations, not just over rates but also over UnitedHealthcare’s demand that the hospitals notify the insurance company within 24 hours after a patient’s admission. If a hospital failed to do so, UnitedHealthcare would cut its reimbursements for the patient by half. ... UnitedHealthcare says the proposed rule is meant to improve the quality of care and cut costs by allowing insurance case managers to jump in right away. The hospitals say that having their reimbursement cut in half is too much to pay for a clerical error, and that the revenue drain would ultimately hurt their patients. ... UnitedHealthcare is negotiating or imposing similar rules at hospitals across the country, and often meeting fierce opposition. Tennessee passed a law saying the penalty would not apply on weekends or federal holidays, when hospitals are short-staffed. Florida hospital officials said that the new rule could play a role in coming contract negotiations there and that the state hospital association had asked Florida’s insurance regulators to monitor the situation."

(Candidate?) Ford calls for “more focused” bill: In a NYT op-ed, Harold Ford, Jr., the former House Democrat from Tennessee who's playing footsie with a Senate bid against New York Sen. Kristen Gillibrand, tells his former — and possibly future — colleagues to "pass a more focused health reform bill that restructures current health care costs before spending more, prohibits insurance companies from denying coverage for pre-existing conditions, enacts responsible reform on malpractice suits and extends health coverage to all children. And we must allow states to have input into the expansion of health coverage, as they will have to pay for much of the reform themselves. This program isn’t all that Democrats wanted from health care reform right now, but it’s what the country wants. And it’s what the country can afford."

(EDITED BY TIM ALBERTA)

** Congressional Democrats are working to finalize health care reform legislation. As the process moves forward, the Center for Medicine in the Public Interest Advance and their national grass-roots campaign Hands OFF My Health strongly urges Congress to keep their HANDS OFF the health care decisions of American patients. Whether the public option, a federalized exchange, or an appointed health care “czar” and new superbureaucracy, more government control over American health care will have far-reaching consequences for patient care, medical services and the practice of medicine. Government-run health care in whatever form or whatever name will eviscerate individual choice, cost taxpayers billions and dramatically increase waiting times for appointments, tests and new procedures. Increasing access and improving quality should be the foundation of national reform, rather than government programs and new bureaucracies that will only stifle innovation and reduce treatment options for patients and providers. To take action visit www.handsoffmyhealth.org. **

** A message from PhRMA: Diabetes is a complex disease affecting more than 30 million Americans – with one-in-ten living in DC, Maryland and Virginia having the disease. Thanks to advances in diabetes care, patients around the country are living longer, healthier lives. Take five-year-old Rhys for example [link to his I’m Not Average profile]. He was diagnosed with type 1 diabetes at 15-months-old, but today, he is a thriving young boy. This is due in large part to new and innovative medicines developed by researchers and scientists at America’s biopharmaceutical companies. Learn more about the medicines in development for diabetes here. **

Authors:

About The Author

Patrick O'Connor barely knew the difference between the House and Senate when he moved to Washington in the fall of 2001 for a job with ESPN. Through providence (in the form of luck, tutelage and his own muddled judgment) he now understands why members spend so much time on the floor speaking to an empty chamber (It's all about C-SPAN, local news and comments in the Congressional Record - just ask Bob Ney). In his two and a half years covering Congress, he has spent a surprising amount of time reading court filings - and knows more convicted felons than he ever thought he would (again, see the affable Mr. Ney) - but that only adds to the fun.

In his previous jobs, he has learned how to drive a backhoe, shuck an oyster and read the daily racing form (although he still lacks the skill to place an informed bet), and he remains thankful for each of his previous posts. He (barely) graduated from Northwestern in 1999 and (miraculously) earned a master's from Columbia in 2004. A Seattle native, he is a bandwagon Bears fan (most of his family lives in Chicago), and he is trying to adopt an affinity for either the Wizards or the Nationals in order to bond with his adopted home. That said, he remains vehemently opposed to the Redskins and their nauseating over-coverage in the DC metro region. In his free time, he reads, spends time at Stetson's (a bar) and walks his girlfriend's dog, Baxter.